Collaboration is the key to reaching people before their alcohol use becomes terminal, agreed participants at a DDN/Addiction Professionals webinar. DDN reports.
Alcohol mortality statistics make for grim reading. The Office for National Statistics (ONS) report that alcohol-specific deaths – where the death is a direct consequence of alcohol misuse – have risen by 11.3 per cent over the last 20 years. In 2019 there were 7,565 deaths related to alcohol in the UK.
As Dr Steve Brinksman pointed out, this was just ‘the tip of an iceberg’ as there were so many other conditions in which alcohol played a significant factor. While there had been a lot in the press about increased alcohol consumption during COVID, ‘the vast majority of alcohol-specific deaths are not acute deaths’ but related to people’s drinking patterns in the years running up to the pandemic.
Brutal budgets
So with the graphs showing a steady increase since 2001, how had we ended up in this situation – and what could we do to reverse the trend? Kieran Doherty, head of quality and governance at Inclusion, believed that alcohol services had been eroded by changes to the way they were funded and commissioned. ‘Moves to competitive tendering and the brutal reductions in local authority budgets mean that alcohol services have been squeezed to near extinction,’ he said.
Another factor had been the move to integrated substance misuse services, which had led to a loss of specialism and people, including the nurses, medics, psychologists, counsellors, recovery workers, community support workers and social workers who made up the multi-skilled team. ‘If we’re going to attend to alcohol problems across the system it needs to be working with colleagues in primary care,’ he said.
Outreach work had suffered and there were only five NHS detoxification units in operation now – a stark reduction in the last 20 years. The Carol Black review, while welcomed, ‘didn’t specifically look at alcohol, which for me pretty much showed where people’s priorities were,’ said Doherty. The alcohol strategy promised for 2019 had not materialised and he was concerned that the alcohol focus could be ‘further diluted’ in the forthcoming national addiction strategy.
The problem with all of this was that ‘people who are coming into our services now are really quite poorly by the time they get to us’. The opportunity for early improvement interventions had been lost and staff were increasingly doing end of life care.
Back in the 1980s and ‘90s there were alcohol surgeries, residential services, drop-in centres, detoxification services – ‘all by different providers working together’. While those days were gone, we needed to ‘look at how we link into our wider networks’, he said. Commissioning had to improve, with alcohol services commissioned as part of an integrated care system.
Separate and siloed
The loss of connection with primary care had led to services becoming ‘too separate, too siloed’, agreed Kate Hall, head of operations in the substance misuse division of Greater Manchester Mental Health NHS Foundation Trust. Were we focusing on services rather than the individual needs of the service user?
The NHS long term plan had focused on reducing the number of A&E attendances, which felt ‘very reactive’, she said, ‘putting a sticking plaster over the gaping wound’. The feedback from services and service users was that alcohol issues were being treated in isolation from past trauma, adverse childhood experiences and mental health issues.
She also emphasised that there needed to be an overhaul of the competency framework to specify appropriate training and the expected level of competence and qualifications. She hoped that restructuring post-PHE would help to fill the gap left by the demise of the National Treatment Agency, by allowing ‘strategic leaders to work together to respond to this significant agenda of mortality’.
In the meantime there were ‘pockets of good practice’ in services. Greater Manchester clinical commissioning groups had been using Radar – the rapid access to detox acute referral pathway – which took referrals directly from the A&E departments across Greater Manchester to eight collaboratively commissioned beds.
‘What we realised was that there was a treatable moment,’ said Hall. People were presenting at A&E with alcohol-related seizures and half of them had had no previous connection with alcohol services. Radar had become ‘a tool in the armoury across Greater Manchester to reduce alcohol-related hospital admissions’ but it was also ‘a great opportunity to do something collaborative’. Liverpool John Moores University’s independent evaluation had confirmed successful completions of more than 90 per cent.
Lived Experience
With the talk of collaboration and the central involvement of primary care, it was time to ask someone with lived experience of alcohol problems about her route to treatment. Aimee explained how she decided to go to her GP to find out what support was available when her drinking had led to a lot of mental health problems, including anxiety and depression.
‘I was lucky with the timing – it was pre-COVID and I was able to get an appointment with my GP fairly quickly,’ she said. ‘Like with any addiction you have to strike while the iron is hot, as soon as you want to get help.’
She was referred swiftly by her GP to Forward Leeds and attended her first appointment, where she was offered a test and found she was pregnant – ‘so I immediately stopped drinking and it was like all of those addiction problems had completely gone away.’
The problems soon returned. She suffered a miscarriage and with COVID just starting she was isolated from family and friends. ‘Before I knew where I was, I was drinking in the exact same way as I was before my pregnancy.’ Her tolerance was low, yet she thought she could drink as much as before.
‘As soon as I had a drink I was suicidal,’ she says. ‘But then I realised I didn’t actually want to die, I just needed to have a different life.’ Then she had a well-timed intervention – her previous contact at Forward Leeds called her to see how her pregnancy was going. ‘I told her that I had had the miscarriage and that I wasn’t in a good way and we decided to work together.’
Initially through telephone appointments, they worked on reducing Aimee’s drinking and began to address her mental health problems. She learned coping mechanisms that have helped her deal with situations and enjoy things she thought she never would.
Her treatment included a programme called Five Ways that taught her about the science of addiction and the risks of drinking. It helped her to have ‘that little bit extra and that focus’, knowing how dangerous alcohol could be.
More luck than judgement
While Aimee’s experience had been positive on the whole, there were elements of ‘more by luck than judgement’, said Brinksman, which were learning points for us as healthcare professionals. It had been so important that the Forward Leeds worker had phoned Aimee to see how she was, showing the ‘massive impact’ of a seemingly throwaway moment.
Reflecting on contributions to the webinar, he said that while ‘obviously there needs to be a strong focus on people with very advanced disease’, as a GP he thought about all the people over the years who became alcohol dependent – but whom he’d seen at some point when they weren’t. ‘How many interventions earlier on may have had positive impacts on people’s lives?’ he wondered. Could a GP – or anyone involved in the treatment chain – have stopped some of that progression?
The webinar has been added to free resources at the Addiction Professionals website, where you’ll find information and expertise on a wide range of topics to support practitioners: www.addictionprofessionals.org.uk/free-resources
Read Kieran Doherty’s ideas for designing an alcohol service at the NHS APA blog: www.nhsapa.org/post/no-light-at-the-end-of-the-bottle